Event Notification Report for March 27, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/26/2003 - 03/27/2003
Power Reactor
Event Number: 39705
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DONALD STRAKA
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DONALD STRAKA
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/27/2003
Notification Time: 13:51 [ET]
Event Date: 03/27/2003
Event Time: 09:43 [MST]
Last Update Date: 03/27/2003
Notification Time: 13:51 [ET]
Event Date: 03/27/2003
Event Time: 09:43 [MST]
Last Update Date: 03/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
BLAIR SPITZBERG (R4)
BLAIR SPITZBERG (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 98 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP DUE TO CONDENSER TUBE RUPTURE
The following information was received from the licensee via facsimile:
"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On March 27, 2003, at approximately 09:43 MST Palo Verde Unit 1 experienced a manual reactor trip from approximately 98% rated thermal power due to a condenser tube rupture. Unit 1 was at normal operating temperature and pressure prior to the trip. All CEAs inserted fully into the reactor core. This was an uncomplicated reactor trip. No ESF actuations occurred and none were required. Safety related buses remained energized during and following the reactor trip. The offsite power grid is stable. No significant LCOs have been entered as a result of this event. There was no loss of normal heat removal capabilities, or loss of any safety functions associated with this event. No major equipment was inoperable prior to the event that contributed to the event. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.
"Unit 1 is stable at normal operating temperature and pressure in Mode 3. There is no estimated time and date for the Unit 1 restart at the time this call is being made."
Palo Verde Units 2 and 3 were unaffected by the Unit 1 trip. There were no lifts of primary or secondary power-operated or manual relief valves. Decay heat removal is being provided via condenser clean-up long path recirc and normal cooldown via the unaffected condenser. Prior to the trip, chloride levels in the steam generators were measured at 25 ppm and rising. Plant abnormal operating procedures require a manual reactor trip at 35 ppm chloride. There is no indications of primary-to-secondary leakage.
The licensee has notified the NRC Resident Inspector.
The following information was received from the licensee via facsimile:
"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.
"On March 27, 2003, at approximately 09:43 MST Palo Verde Unit 1 experienced a manual reactor trip from approximately 98% rated thermal power due to a condenser tube rupture. Unit 1 was at normal operating temperature and pressure prior to the trip. All CEAs inserted fully into the reactor core. This was an uncomplicated reactor trip. No ESF actuations occurred and none were required. Safety related buses remained energized during and following the reactor trip. The offsite power grid is stable. No significant LCOs have been entered as a result of this event. There was no loss of normal heat removal capabilities, or loss of any safety functions associated with this event. No major equipment was inoperable prior to the event that contributed to the event. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.
"Unit 1 is stable at normal operating temperature and pressure in Mode 3. There is no estimated time and date for the Unit 1 restart at the time this call is being made."
Palo Verde Units 2 and 3 were unaffected by the Unit 1 trip. There were no lifts of primary or secondary power-operated or manual relief valves. Decay heat removal is being provided via condenser clean-up long path recirc and normal cooldown via the unaffected condenser. Prior to the trip, chloride levels in the steam generators were measured at 25 ppm and rising. Plant abnormal operating procedures require a manual reactor trip at 35 ppm chloride. There is no indications of primary-to-secondary leakage.
The licensee has notified the NRC Resident Inspector.
General Information or Other
Event Number: 39707
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT AVAILABLE
Region: 1
City: State: NY
County:
License #: NOT AVAILABLE
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU (FAX)
HQ OPS Officer: HOWIE CROUCH
Licensee: NOT AVAILABLE
Region: 1
City: State: NY
County:
License #: NOT AVAILABLE
Agreement: Y
Docket:
NRC Notified By: ROBERT DANSEREAU (FAX)
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/27/2003
Notification Time: 17:40 [ET]
Event Date: 03/27/2003
Event Time: 00:00 [EST]
Last Update Date: 03/27/2003
Notification Time: 17:40 [ET]
Event Date: 03/27/2003
Event Time: 00:00 [EST]
Last Update Date: 03/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAMELA HENDERSON (R1)
E. WILLIAM BRACH (NMSS)
PAMELA HENDERSON (R1)
E. WILLIAM BRACH (NMSS)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was received from the New York State Department of Health, Bureau of Environmental Radiation Protection:
"This notice is in regard to a medical misadministration involving a Novoste Beta-Cath IVB 3.5F system, Model A1767 with AEAT Model SIC W.2 source train. The event occurred on March 25, 2003.
"Two attempts to advance the source train into the delivery catheter were unsuccessful. A third (and final) attempt resulted in the source train becoming stuck in the patient's femoral artery, somewhere in the lower groin area. The sources could not be returned to the base unit. The treatment team then removed the catheter, with the source extended, and placed these items into the emergency bailout box.
"The licensee estimated that the patient received an exposure of 250 Rads to an area of the femoral artery in the lower groin area. The oncologist and cardiologist decided not to proceed with IVB treatment of this patient. Hospital staff concluded that the misdirected radiation exposure would not have a significant health effect on the patient.
"This event meets the reporting requirements in 10 NYCRR 16. The facility will investigate the circumstances, procedures, training, history of use, etc., and will submit a written report within 7 days. The device, including catheter and hydraulic attachment (syringe) will be sent to the vendor for evaluation."
The following information was received from the New York State Department of Health, Bureau of Environmental Radiation Protection:
"This notice is in regard to a medical misadministration involving a Novoste Beta-Cath IVB 3.5F system, Model A1767 with AEAT Model SIC W.2 source train. The event occurred on March 25, 2003.
"Two attempts to advance the source train into the delivery catheter were unsuccessful. A third (and final) attempt resulted in the source train becoming stuck in the patient's femoral artery, somewhere in the lower groin area. The sources could not be returned to the base unit. The treatment team then removed the catheter, with the source extended, and placed these items into the emergency bailout box.
"The licensee estimated that the patient received an exposure of 250 Rads to an area of the femoral artery in the lower groin area. The oncologist and cardiologist decided not to proceed with IVB treatment of this patient. Hospital staff concluded that the misdirected radiation exposure would not have a significant health effect on the patient.
"This event meets the reporting requirements in 10 NYCRR 16. The facility will investigate the circumstances, procedures, training, history of use, etc., and will submit a written report within 7 days. The device, including catheter and hydraulic attachment (syringe) will be sent to the vendor for evaluation."
General Information or Other
Event Number: 39708
Rep Org: ALABAMA RADIATION CONTROL
Licensee: THOMPSON ENGINEERING AND TESTING, INC.
Region: 2
City: State: AL
County:
License #: 694
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER (FAX)
HQ OPS Officer: HOWIE CROUCH
Licensee: THOMPSON ENGINEERING AND TESTING, INC.
Region: 2
City: State: AL
County:
License #: 694
Agreement: Y
Docket:
NRC Notified By: DAVID WALTER (FAX)
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/27/2003
Notification Time: 15:18 [ET]
Event Date: 03/27/2003
Event Time: 00:00 [CST]
Last Update Date: 03/27/2003
Notification Time: 15:18 [ET]
Event Date: 03/27/2003
Event Time: 00:00 [CST]
Last Update Date: 03/27/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RUDOLPH BERNHARD (R2)
E. WILLIAM BRACH (NMSS)
RUDOLPH BERNHARD (R2)
E. WILLIAM BRACH (NMSS)
AGREEMENT STATE REPORT - LOST TROXLER MOISTURE/DENSITY GAUGE
The following information was received from Alabama Office of Radiation Control via facsimile:
"The Agency has been notified by Thompson Engineering and Testing, Inc. that a Troxler Model 3440 Gauge (serial #32128) containing a maximum of 9 millicuries of cesium 137 and 44 millicuries of americium 241/beryllium is missing. They have conducted a search of many of their Alabama offices, and have been unable to locate it. Since their records do not show this device being used in some time, it had been in storage, and was not detected as lost until the six month leak test was due. They are continuing to search for the gauge, and will notify this office of their findings."
The following information was received from Alabama Office of Radiation Control via facsimile:
"The Agency has been notified by Thompson Engineering and Testing, Inc. that a Troxler Model 3440 Gauge (serial #32128) containing a maximum of 9 millicuries of cesium 137 and 44 millicuries of americium 241/beryllium is missing. They have conducted a search of many of their Alabama offices, and have been unable to locate it. Since their records do not show this device being used in some time, it had been in storage, and was not detected as lost until the six month leak test was due. They are continuing to search for the gauge, and will notify this office of their findings."